Ruptured heterotopic pregnancy presenting with relative bradycardia in a woman not receiving reproductive assistance

Spontaneous Heterotopic Pregnancy Associated with Massive Intraperitoneal Haemorrhage and a Normal Heart Rate, Illustrating the Concept of Relative Bradycardia

A 28-year-old, 9 and a half weeks pregnant (spontaneous conception) multigravida presented with abdominal pain and vaginal bleeding. On examination, her abdomen was diffusely tender, particularly in the right iliac fossa, though guarding was absent. Transabdominal and transvaginal ultrasonography demonstrated a viable intrauterine pregnancy and large-volume intraperitoneal haemoperitoneum; the right ovary could not be identified. The patient became hypotensive with decreased responsiveness, yet her heart rate remained normal. She proceeded to surgery where a ruptured right tubal ectopic pregnancy was identified and right salpingectomy was performed. Estimated blood loss was 3900ml. Postoperative recovery was uneventful. Ultrasound 3 days after surgery demonstrated a viable intrauterine pregnancy of gestational age 9 weeks + 1 day. The patient remains well. Her anomaly scan at 20 weeks and 6 days showed normal growth, amniotic fluid, and Dopplers with no obvious structural defects. She is currently 27 weeks pregnant and will be rescanned at 36 weeks.

Two cases of heterotopic pregnancy: review of the literature and sonographic diagnosis in the emergency department

We present 2 recent cases of heterotopic pregnancy in which bedside sonography performed by the treating emergency physician was used to identify the heterotopic pregnancy and facilitate prompt gynecologic intervention. The cases, the sonographic approach to the diagnosis of heterotopic pregnancy, and a review of the literature are presented.

Successful conservative management of ruptured ovarian cysts with hemoperitoneum in healthy women

Study Objective

To determine the success rate of the “intended conservative management strategy” of ruptured ovarian cysts with hemoperitoneum and the risk factors for surgical interventions in healthy women of reproductive age.

Methods

Patients who visited the emergency department with abdominal pain and were diagnosed with a ruptured ovarian cyst with hemoperitoneum between August 2008 and June 2013 were included in this retrospective study. The diagnosis of the ruptured ovarian cysts and hemoperitoneum was based on the clinical symptoms, physical examination and ultrasound and CT imaging. The rate of surgical interventions and the risk factors for surgical intervention were determined.

Results

A total of 78 women were diagnosed with a ruptured ovarian cyst with hemoperitoneum. Most patients (80.8%, 63/78) were managed conservatively, and 19.2% of the patients (15/78) required a surgical intervention. In the multiple logistic regression analysis, the diastolic blood pressure (dBP) (odds ratio [OR] of 0.921 with 95% confidence interval [CI] of 0.855–0.993) and the depth of the total pelvic fluid collection in CT (DTFC_CT) (OR 1.599 with 95% CI 1.092–2.343) were the significant determining factors of surgical intervention after adjustment. The rate of surgical intervention was 6.5% vs. 15.8% vs. 77.8% in the patients with neither dBP≤70 mmHg nor DTFC_CT≥5.6 cm, those with only one of those features, and those with both, respectively.

Conclusion

Most cases of ruptured ovarian cysts with hemoperitoneum can be managed conservatively. A low diastolic blood pressure and a large amount of hemoperitoneum suggest the need for surgical intervention.

Surgical and obstetric outcomes of laparoscopic management for women with heterotopic pregnancy

AIM

The aim of this study was to investigate the obstetric outcomes and clinical efficacy of laparoscopic surgery for women with heterotopic pregnancy.

MATERIAL AND METHODS

We conducted a retrospective study of women who had undergone laparoscopic surgery for heterotopic pregnancy. The primary outcome was the feasibility of laparoscopic surgery for the treatment of heterotopic pregnancy and the secondary outcomes were obstetric outcomes.

RESULTS

Seventeen women underwent laparoscopic surgery for heterotopic pregnancy: 14 with tubal heterotopic pregnancies and three with cornual heterotopic pregnancies. There were no intraoperative or postoperative complications. Of these women, 13 delivered 14 healthy babies, whereas two failed to maintain their pregnancies; one had a missed abortion 2 weeks after the surgery and the other had a miscarriage due to preterm premature rupture of the membrane at 16 gestational weeks. The remaining two women have ongoing pregnancies.

CONCLUSION

Laparoscopic surgery performed by experienced surgeons is a feasible and beneficial surgical modality for treating heterotopic pregnancy.

Heterotopic pregnancy

Heterotopic pregnancy is a life-threatening condition. A recent case at our institution prompted a systematic review of the literature from 2005 to 2010. In the majority (71%) of cases reviewed, risk factors for a heterotopic pregnancy were present. However, in several instances (33%), previous sonographic reports of a normal intrauterine pregnancy gave false reassurance. These results highlight the complexity of diagnosis. In addition, our findings were compared with two previous reviews covering cases from 1971 to 2004. This comparison highlighted two important trends: first, the increasing role of ultrasound in the definitive diagnosis of a heterotopic pregnancy, and second, the development of conservative approaches to management. Medical knowledge and technology may be improving, but ultimately, even in the presence of a known intrauterine pregnancy, the simple dictum 'think ectopic' must not be forgotten.

Relative bradycardia in hypotensive trauma patients: a reappraisal

BACKGROUND

The inability to mount tachycardia (T) after trauma-related hypotension is labeled relative bradycardia (RB). The objective of this study was to examine RB incidence and prognosis in a large cohort of patients.

METHODS

The Los Angeles County Trauma System database, consisting of five Level I and eight Level II trauma centers, was queried for all adult (>14 years) hypotensive (systolic blood pressure [SBP] <or=90) trauma patients admitted between 1998 and 2005. RB was defined as SBP <or=90 with heart rate (HR) <or=90, and T was defined as SBP <or=90 with HR >90. Demographics, injury severity, mechanism, and outcomes were compared between the RB and T groups. Multivariate logistic regression was used to determine significant risk factors for mortality.

RESULTS

Of 130,906 adult trauma patients, 7,123 (5.4%) were hypotensive. After excluding patients dead on arrival and those with missing data, 3,727 patients were identified. RB was observed in 1,630 (44%) of patients, whereas T was observed in 2,097 patients (56%). RB patients were older (39.8 +/- 18.6 years vs. 35.3 +/- 17.0 years, p < 0.0001), less severely injured (injury severity score 18.0 +/- 14.2 vs. 20.5 +/- 15.3, p < 0.0001), more hypotensive (SBP 64.7 +/- 31.6 vs. 76.2 +/- 15.1, p < 0.0001), and had less abdominal trauma (abdomen abbreviated injury score 2.9 +/- 1.2 vs. 3.2 +/- 1.1, p < 0.0001) than their tachycardic counterparts. In addition, the mortality was significantly higher in the RB group compared with the T group (30.1% vs. 22.6%, p < 0.0001). Overall, RB had a higher mortality among all subgroups except older patients (age >or=55; 27.7% vs. 35.2%, p = 0.045) and patients with a higher Glasgow coma scale score (>or=12; 5.3% vs. 11.2%, p < 0.0001). Logistic regression identified RB as an independent risk factor for mortality (odds ratio, 1.60; 95% confidence interval, 1.33-1.94; p < 0.0001). When RB was further divided into two groups, observed mortality for HR <60 and HR 60 to 90 was 62.4% and 9.7%, respectively.

CONCLUSIONS

RB was common in hypotensive adult trauma patients; overall, it was associated with increased mortality. Patients older than 55 years and with a higher Glasgow coma scale score demonstrated decreased mortality with RB. When RB was further divided, a HR between 60 and 90 demonstrated a significant lower mortality compared with a HR <60 and to T.

Heterotopic Pregnancy Following Reversal of Tubal Ligation

We describe the case of a 37-year-old woman who had undergone reversal of tubal ligation with subsequent heterotopic pregnancy. We review the initial radiological evaluation of heterotopic pregnancies and the subsequent radiologic findings following appropriate therapy.

Heterotopic Pregnancy Diagnosed by Emergency Ultrasound

We present a case of heterotopic pregnancy rapidly diagnosed by an emergency physician. To the best of our knowledge, this is the first report of an emergency physician using bedside ultrasound to diagnose an ectopic pregnancy present simultaneously with an intrauterine pregnancy. Other unique features of this case include the diagnosis being made on initial evaluation and the patient's lack of risk factors for heterotopic pregnancy. A review of the cases of heterotopic pregnancy reported in the emergency medicine literature, the rising prevalence of the disease, and factors that may facilitate in making the diagnosis are discussed as well.

Heterotopic pregnancy: two cases and a comparative review

OBJECTIVE

To analyze the incidence, diagnostic, and therapeutic management of heterotopic pregnancy by comparing a review for the 1971-1993 period with the one carried out in the present study (1994-2004).

DESIGN

Review of the literature.

SETTING

University teaching assisted reproductive technology (ART) center.

PATIENT(S)

Two case reports included in a comparative review of the literature on heterotopic pregnancy.

INTERVENTION(S)

Review of the published literature from January 1994 to December 2004 was performed by means of MEDLINE database. Medical subject heading words used were: heterotopic pregnancy, assisted reproductive technology, and ectopic pregnancy. A comparison with a previously reported review, including cases from 1971 to 1993.

MAIN OUTCOME MEASURE(S)

Comparative study of the diagnosis and treatment of ectopic pregnancy.

RESULT(S)

During the 1971-1993 period the definitive diagnosis of heterotopic pregnancy was performed by laparoscopy or laparotomy in 59% of cases. This proportion increased to 74% from 1994 to 2004. Likewise, the percentage of cases in which an early diagnosis was possible (performed before the ninth week of pregnancy) did not vary in any of the time periods evaluated (71% vs. 74%).

CONCLUSION(S)

Despite the increased medical knowledge and use of improved reproductive technologies, heterotopic pregnancy still remains a diagnostic and therapeutic challenge to practitioners.